Macroeconomics and Health (CMH)

Meeting to facilitate CMH implementation in the Eastern Mediterranean Region

Panoramic view of the Fez medina

The WHO Regional Office for the Eastern Mediterranean held a “Meeting to facilitate the implementation of the recommendations of the Commission on Macroeconomics and Health in the Eastern Mediterranean Region" in Fez, Morocco from 13 - 14 June 2003. Representatives from seven countries of the Eastern Mediterranean region came together with Country, Regional and the CMH Support Unit staff to discuss how to adapt the global CMH framework to the priority needs of Eastern Mediterranean countries, to revise six MH national plans and to draft a Regional macroeconomics and health concept paper. The paper will help guide country-level activities region-wide and define some broad benchmarks to assess progress. Another issue discussed was preparation for country participation in the 2nd Consultation on Macroeconomics and Health, Increasing Investments in Health Outcomes for the Poor, which will take place October 2003.

Yemen government representative presents MHS action plan

Country and regional participants emphasized that the process to develop health investment plans must generate cross-sectoral support as well as build donor confidence. This is dependent upon the MHS becoming fully integrated into existing national poverty reduction schemes. In line with the country-led nature of the MHS process, WHO should strive to work with governments to produce the local evidence-base on the burden of disease impacting the poor and vulnerable, and then define cost-effective essential health interventions that will help push for new health strategies.

WHO Representative delivers Djibouti country information

Participants felt improved governance was necessary to the success of strategies to scale up the health system. Workshop discussions stressed that operationalizing an MHS requires a solid government commitment to reallocate national budgets and seek additional internal resources for health. The success of health investment plans will also rely on clear outcome tracking and strong supervision. Moreover, plans must realistically address known constraints and offer practical steps to remove these barriers. Finally, investment plans should show a coherent path towards national achievement of the Millennium Development Goals (MDGs).


The tragic loss of WHO representative Mr. Fassi Fehri F. just prior to the CMH Regional meeting on June 13-14 2003 did not prevent the country delegation from bringing to the workshop a draft plan of action for beginning a national CMH process. Noting that the Ministry of Health budget has declined from 5.7 to 4.2 % of the total budget, the country delegation places a high priority on raising awareness among other ministries and the most senior levels of government of the centrality of health to developmental strategies. Djibouti’s acting WHO Representative felt one short-term objective is to strengthen the consensus within the Ministry of Health for building a multi-sectoral mechanism to develop health investment plans.

Djibouti’s Phase 1 country plan of work calls for the formation of a national macroeconomics steering committee and CMH technical group to be directed by the Health Ministry. Another key objective for Phase 1 is to map out a strategic action plan for increasing intersectoral collaboration for investing in all the key determinants of health, including water, sanitation and education. Discussions with the Secretary general for the Ministry of Health and the Director of Budgets for the Ministry of Financing and Planning led to revisions in the Djibouti workplan and to their commitment to submit a revised plan of action to Regional office & HQ for Phase 1 activities in the near future.

The Islamic Republic of Iran

In June 2003 Iran sent a team to the Regional Office for the “Meeting to facilitate CMH implementation in the Eastern Mediterranean Region.” Country representatives noted that a 5-year health & development plan is being finalized now. This plan should create a window of opportunity for applying advocacy and communication tools to raise awareness among the highest levels of government on the centrality of health to poverty and sustainable development strategies. They also felt that the basis of such multi-sectoral planning should involve reliance on Iran's internal resources, with resource reallocation once evidence has been developed and analysed.

Participants noted that medical education is already integrated under the Ministry of Health, with provincial health ministers also filling the role of medical school deans. Poverty alleviation has long been an integral part of public sector strategies, and Iran is building upon the success of recent initiatives to increase community involvement in health. To achieve the Millennium Development Goals (MDGs), the country wishes to increase the effectiveness and reach of health service delivery systems to provide essential interventions. One key gap they have identified is the weakness of current information management systems to generate an analysis useful to decision-makers. WHO is being requested to aid in identifying IT tools, and the Regional Office and HQ will work with Iran to explore various options to remove this constraint to progress.

Agreement was reached with Iran to include a timeline of activities, budget and specific and measurable products. They also requested technical support to develop the revised plan, which the Regional Office will coordinate. WHO-HQ staff could assist if the Region feels it is of use.


During the Regional workshop in June 2003, the General Secretary of the High Health Council expressed his belief that the CMH process would be successfully implemented in Jordan. He was joined by the assistant General Secretary from the Ministry of Finance and the Coordinator of the Community Infrastructure Programme from the Ministry of Planning, who also gave strong support to implementing the MHS process. They noted that one preliminary objective was to attempt to disaggregate available burden of disease data by income quintiles. This would be a critical milestone in the process to define a range of cost-effective interventions to address the needs of the poor and vulnerable. The Jordanian delegation was very focused on conducting a Cost-Effectiveness Analysis (CEA) to identify the most effective interventions to meet the health needs of all communities. They expressed a desire for WHO resources & assistance in developing a CEA of current system & services.

Their revised Phase 1 plan will also include an assessment of available data on Burden of Disease (BOD) and the identification of the focus of a CEA to assess gaps and identify research needed. The team also agreed to include as a Phase 1 objective the defining of, and capitalizing upon, realistic entry points for the MHS process into existing poverty & development mechanisms.

The team presented a revised workplan which incorporated two themes that surfaced during the Regional workshop: integrate the CMH process into current efforts for sustainable development; and capitalize on previous experiences and lessons learnt to reduce barriers and optimize opportunities to place health at the centre of the development agenda. For example, the Jordanian delegation felt the experiences of their Health Village Programme are an opportunity upon which to build, as this is one way of stemming the loss of medical and other health professionals from rural areas. This loss is one of the biggest constraints to effectively meeting the needs of Jordan’s poor.


Country representatives from Pakistan shared their views at the June meeting. They explained that Pakistan follows a multi-pronged approach to reducing poverty, based on the Poverty Reduction Strategy Paper (PRSP) and incorporating 1) acceleration of economic growth, 2) governance reforms, 3) expanding social safety nets, and 4) investing in human resources. Health sector investments are viewed as part of the Poverty Reduction Plan, with attention directed to the provision of primary care and community based initiatives. Good governance is seen as the foundation of the current health sector reform process.

As Pakistan’s Poverty Reduction Strategy Paper (PRSP) is already finalized, the objective will be to disseminate the key messages of the CMH report, translate them into the local macroeconomic context and use them to define research to construct an evidence base for placing health more centrally in the PRSP. A timeline and specific products for the workplan were requested in order to identify expected products and determine how funds will be applied. The WHO Representative for Pakistan stressed that technical support is more urgently needed than financial support, and that increasing local institutional capacity was a critical objective of the MHS. These comments will be reflected in the work plan submitted by Pakistan.


At the meeting, Sudan presented its experiences as a large country that must cope with almost 1 million internally displaced people and a rural population close to 10 million. Within the context of severe civil strife and a large trans-national migrant population, long-term strategic health planning must rely on coordinating a diverse network of internal and external partners, aid agencies and other agents. Since the initial push for primary health care, there has been a marked inability to foster intersectoral collaborations or achieve coordination of various plans, even within one public sector.

The PRSP is merely one of many United Nations initiatives, and the delegation felt some integrated framework to rationalize all these initiatives was needed. They express the hope that the CMH would focus on building up existing networks and strengthening partner networks that will lead to a real cross-sectoral dialogue and participation in poverty reduction efforts.


Yemen attended the meeting in June 2003, accompanied by the Assistant Deputy Minister for Foreign Affairs from the Finance Ministry and the Director General of Projects from the Ministry of Planning. Yemen's strategic priorities for Phase 1 work centre around dissemination of key messages, generation of a pro-active debate among senior decision-makers on how to make health central to development strategies, rendering the NCMH fully operable and setting the stage for Phase 2 work.

The team identified determining gaps in burden of disease of the poor and vulnerable and creating an advocacy strategy as additional key early MHS priorities. They also will aim to build up a consensus among stakeholders for the need to create and implement a multi-sectoral long-term plan of health investments. Entry points for CMH are identified as the HS reform initiative, which includes implementation of District System health. The PRSP process will be the vehicle for operationalizing the CMH process.


Oman participated in the EMRO Regional meeting in Morocco, June 13- 14 2003. Country representatives noted that encouraging partnerships and linkages between the Ministries of Finance, Health and Planning requires an internal and an external strategy. WHO's responsibility is to provide a forum where health ministers can communicate their needs to finance ministers, and where finance ministers can discuss the criteria they require to allocate more funds to health services.


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